387782_Well Construction - GW1_20101008

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3117-A
1 WELL CONTRACTOR
John Hardin
Well Contractor (Individual) Name
Hardin's Pump and Compressor
Well Contractor Company Name
3068 Old Thomasville Road
Street Address
Winston-Salem NC 27107
City or Town State Zip Code
336 ) 769-9128
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-4
3 WELL USE (Check One Box) Monitoring NI/ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED 9/21/2010
4 WELL LOCATION
1598 C C Camp Road
(Street Name Numbers Community Subdivision, Lot No , Parcel Zip Code)
CITY Elkin COUNTY SUrrV
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley pfnat ❑Ridge ❑Other
LATITUDE 36
° 16 ' 50 0000
LONGITUDE 80 ° 47 ' 190000
" DMS OR 3x xxxxxxxxx DD
" DMS OR 8x xxxxxxxxx DD
Latitude/longitude source I,Ij3PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
Fikin Mt/nicin I Alrnort 0-000030
Facility Name Facility ID# (if applicable)
1598 C C Camn Road
Street Address
Flkin NC 28621
City or Town State Zip Code
Town of Flkin
Contact Name
226 N Bridae StrPPt
Mailing Address
Flkin
City or Town
t 336fi 835-9800
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 40'
NC 28621
State Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES ❑
NO E
c WATER LEVEL Below Top of Casing 32.25
(Use "+" if Above Top of Casing)
FT
3,37'782
d TOP OF CASING IS 0 FT Above Land Surface`
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 10 Ft 2" Sch 41 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 1 Bottom 6 Ft Portland Pour
Top 6 Bottom 8 Ft Bentonite Pour
Top Bottom Ft
9 SCREEN Depth Diameter
Top 10 Bottom 40 Ft 2 in
Top Bottom Ft in
Top Bottom Ft in
Slot Size Material
0 01 in PVC
in
In
10 SAND/GRAVEL PACK
Depth Size Material
Top 8 Bottom 40 Ft #3 Filter Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 20 Orange/CLAY w/ silt, damp
20 / 40
12 REMARKS
Dark orange. CLAY w/ silt, moist
CEIVED
OCT - 8 2010
information Processing Unit
DWQ/BOG
EBY CERTIFY HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
WELL •I STRUCTIONSTANDAR AN THAT A COPY OF THIS
:virtu nr� BEE y/IDED TO THE WELL NE
k �ct% %D 14A)
GN ' E OF CERTIFIED WEL ONTRACTOR D E /,
/xi 4 j /174-
PRINTED NAME OF PERSON NSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processing,,
1617 Mail Service Center, Raleigh, NC 276997161,,Phone [phone]
Form GW-lb
Rev 2/09